High Prevalence of Methicillin-Resistant Staphylococcus Aureus Among Healthcare Facilities and Its Related Factors in Myanmar (2018–2019)
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Tropical Medicine and Infectious Disease Article High Prevalence of Methicillin-Resistant Staphylococcus aureus among Healthcare Facilities and Its Related Factors in Myanmar (2018–2019) Pan Ei Soe 1,*, Wai Wai Han 2, Karuna D. Sagili 3, Srinath Satyanarayana 3 , Priyanka Shrestha 4, Thi Thi Htoon 1 and Htay Htay Tin 1 1 National Health Laboratory, Ministry of Health and Sports, Yangon 11191, Myanmar; [email protected] (T.T.H.); [email protected] (H.H.T.) 2 Medical Statistics Division, Department of Medical Research, Ministry of Health and Sports, Yangon 11191, Myanmar; [email protected] 3 International Union Against Tuberculosis and Lung Disease, South East Asia Office, New Delhi 110016, India; [email protected] (K.D.S.); [email protected] (S.S.) 4 WHO Health Emergencies Programme, Kathmandu 44600, Nepal; [email protected] * Correspondence: [email protected]; Tel.: +95-9-517-2337 Abstract: Background: Antimicrobial resistance (AMR) is a growing global health problem. Staphy- lococcus aureus (SA) is a common bacterium associated with a variety of community and hospital infections. Methicillin-resistant Staphylococcus aureus (MRSA) accounts for most SA related morbidity Citation: Soe, P.E.; Han, W.W.; Sagili, and mortality. In this study, we determined the prevalence and factors associated with SA and K.D.; Satyanarayana, S.; Shrestha, P.; MRSA in Myanmar. Methods: We collected the data retrospectively by reviewing an electronic Htoon, T.T.; Tin, H.H. High register containing the results of bacterial culture and antibiotic susceptibility testing of biological Prevalence of Methicillin-Resistant specimens received from healthcare facilities during 2018–2019. Results: Of the 37,798 biological Staphylococcus aureus among specimens with bacterial culture growth, 22% (8244) were Gram-positive. Among the Gram-positive Healthcare Facilities and Its Related Factors in Myanmar (2018–2019). bacteria, 42% (2801) were SA, of which 48% (1331) were judged as MRSA by phenotypic methods. Trop. Med. Infect. Dis. 2021, 6, 70. The prevalence of MRSA was higher in the older age groups, in female patients, in urine specimens https://doi.org/10.3390/ and specimens received from the intensive care unit and dermatology departments. One site (Site F) tropicalmed6020070 had the highest MRSA prevalence of the seven AMR sentinel sites. Most SA isolates were sensitive to vancomycin (90%) by phenotypic methods. Conclusions: The high prevalence of MRSA indicates a Academic Editors: Olga Perovic, major public health threat. There is an urgent need to strengthen the AMR surveillance and hospital Tom Decroo and Chakaya infection control program in Myanmar. Muhwa Jeremiah Keywords: antimicrobial resistance; hospital infections; MRSA; Gram-positive bacteria; SORT IT; Received: 3 March 2021 operations research Accepted: 20 April 2021 Published: 6 May 2021 Publisher’s Note: MDPI stays neutral 1. Introduction with regard to jurisdictional claims in published maps and institutional affil- Antimicrobial resistance (AMR) is a serious emerging global health problem in this iations. century. Staphylococcus aureus (SA) is an antibiotic-resistant pathogen of significant public health concern [1]. Humans can become infected with SA both in the community and in healthcare settings. SA causes a wide range of human infections like bacteremia, endocardi- tis, skin and soft tissue infections, bone and joint infections and hospital-acquired infections [2]. The inappropriate use of antibiotics contributes to antibiotic resistance in SA. MRSA Copyright: © 2021 by the authors. Staphylococcus aureus SA Licensee MDPI, Basel, Switzerland. (methicillin-resistant ) is a subgroup of . As the name suggests, This article is an open access article MRSA does not respond to common antibiotics, such as methicillin, amoxicillin, and peni- distributed under the terms and cillin. In the United States, the incidence of MRSA bloodstream infections declined from conditions of the Creative Commons 74% to 40% during 2005–2016. Despite this decline, it is estimated that nearly 120,000 SA Attribution (CC BY) license (https:// bloodstream infections and 20,000 SA-associated deaths occurred in 2017 [3]. The Asia creativecommons.org/licenses/by/ Pacific Regional Resistance Surveillance program reported that 26% to 73% of SA isolates 4.0/). from healthcare settings in the region were resistant to methicillin [4]. Trop. Med. Infect. Dis. 2021, 6, 70. https://doi.org/10.3390/tropicalmed6020070 https://www.mdpi.com/journal/tropicalmed Trop. Med. Infect. Dis. 2021, 6, 70 2 of 13 Infection with MRSA remains associated with poorer clinical outcomes and increased healthcare costs. A multicenter study conducted in China between 2013 and 2015 showed that the MRSA infection was significantly associated with higher total hospital cost, longer length of hospital stay, and increased mortality rate as compared to Methicillin-sensitive Staphylococcus aureus (MSSA) infection, especially in patients with underlying diseases such as malignancy or chronic pulmonary diseases [5]. However, evidence from high- income countries proved that implementing an effective hospital infection control program significantly reduces the morbidity and mortality of MRSA-associated infections [6–8]. The improvement in hand hygiene compliance can significantly decrease MRSA rates in hospitals [9]. According to the World Health Organization (WHO) estimate, Myanmar has the high- est MRSA proportion (26%) among the South East Asian countries that reported national data relating to antibiotic resistance. However, this estimate was based on approximately 30 isolates only [1]. To date, there is minimal information on the prevalence of MRSA, morbidity, and mortality in Myanmar from a few publications on microbiological and animal studies [10–12]. A recently published study conducted in a tertiary care hospital in Myanmar revealed that the molecular detection of MRSA accounted for 13.8% [13]. A retrospective study from one hospital examining blood culture results showed a decline in MRSA among SA isolates (38.7% to 18.8%) over eight years [14]. Establishing a proper surveillance system and an effective hospital infection control system is mandatory to minimize the emergence of MRSA and to reduce its spread. Although national guidelines on hospital infection control were developed in Myanmar in 2016, clinicians’ adherence to the guidelines is still low [15]. Besides, guidelines related to antibiotic prescription do not exist at the national level, although some tertiary hospitals have developed their own antibiotic guidelines. This study aimed to determine the prevalence of SA and the factors associated with MRSA in healthcare settings in Myanmar during 2018–2019. The objectives of the study were (1) to assess the number (and proportion) of samples with SA infection among the total biological samples received for bacterial culture and drug susceptibility testing at seven AMR sentinel sites between 2018 and 2019; (2) to describe the antibiotic susceptibility pattern of SA infection and assess the number and proportion with MRSA infection; (3) to describe the demographic and clinical profile of patients and determine their association with MRSA. 2. Material and Methods 2.1. Study Design This was a retrospective descriptive study based on the electronic register record of seven AMR sentinel laboratories in Myanmar. 2.2. Setting 2.2.1. General Setting The Union of the Republic of Myanmar is located in the South East Asian region and bordered by the Bay of Bengal, Andaman Sea, Gulf of Thailand, and the countries of Bangladesh, India, China, Laos, and Thailand. The country is administratively divided into 14 States/Regions and Nay Pyi Taw Union Territory. It has a population of 51.48 million. Healthcare is provided by both the public and private sectors. General practitioner clinics and drug shops are the initial points of healthcare seeking for most populations. Antibiotics are readily available over the counter. 2.2.2. Specific Setting In Myanmar, the AMR surveillance system at the national level is being carried out through seven public hospitals and laboratories, which can cover AMR’s overall situation in Myanmar. Five of them (Site A, B, C, D and E) are located in Yangon Region, covering the Yangon Region population and some population from the lower part of Myanmar. Site F is located in the Mandalay Region, and it covers the population from upper Myanmar. Site G Trop. Med. Infect. Dis. 2021, 6, 70 3 of 13 is located in Nay Pyi Taw Union Territory in the central part of Myanmar, and it covers the population in Nay Pyi Taw Union Territory and surrounding townships. The populations of Yangon Region and Mandalay Region are 7.3 million and 6.1 million, respectively. The distribution of the seven sentinel sites is shown in Figure1. Site F Site G Site D Site E Site B Site A Site C 1 1 Figure 1. Distribution of seven AMR sentinel sites in Myanmar. 2 Figure 1. Distribution of seven AMR sentinel sites in Myanmar 2.2.3. AMR Surveillance in Myanmar 3 The National Action Plan (NAP) to combat AMR has been developed in line with the Global Action Plan of AMR since 2017, with five strategic objectives (awareness, surveil- lance, infection prevention and control, antimicrobial usage, and research and innovation). National Multi-sectoral Steering Committee (NMSC) was organized to provide the neces- sary political commitments to fight against AMR. Five technical working groups (TWGs) were constituted under NMSC to implement the five strategic objectives